Kaplan + Sadock's Synopsis of Psychiatry, 11e

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28.1 Psychoanalysis and Psychoanalytic Psychotherapy

Table 28.1-2 Stages of Psychoanalysis

Table 28.1-3 Patient Prerequisites for Psychoanalysis

Stage one: Patient becomes familiar with the methods, routines, and requirements of analysis, and a realistic therapeutic alliance is formed between patient and analyst. Basic rules are established; the patient describes his or her problems; there is some review of history, and the patient gains initial relief through catharsis and a sense of security before delving more deeply into the source of the illness. The patient is primarily motivated by the wish to get well. Stage two: Transference neurosis emerges that substitutes for the actual neurosis of the patient and in which the wish for health comes into direct conflict with the simultaneous wish to receive emotional gratification from the analyst. There is a gradual surfacing of unconscious conflicts; an increased irrational attachment to the analyst, with regressive and dependent concomitants of that bond; a developmental return to earlier forms of relating (sometimes compared with that of mother and infant); and a repetition of childhood patterns and recall of traumatic memories through transfer to the analyst of unresolved libidinal wishes. Stage three: The termination phase is marked by the dissolution of the analytical bond as the patient prepares for leave-taking. The irrational attachment to the analyst in the transference neurosis has subsided because it has been worked through, and more rational aspects of the psyche preside, providing greater mastery and more mature adaptation to the patient’s problems. Termination is not a hard-and-fast event, and the patient invariably has to continue to work through any problems outside of the therapy situation without the analyst or may need intermittent assistance after analysis has technically terminated. the possibility of psychoanalysis was presented to her, she worried that meant she was “sicker.” Ms. M, however, began reading Freud, realized that analysis was actually recommended for those who are higher functioning, and became intrigued by the idea. She agreed to come 4 days a week for 50-minute sessions. She was the oldest of three children and the only girl. Ms. M’s father, a successful professional, was described as very demand- ing and intrusive, someone who never thought anything was good enough. He had always expected his children to do the “extra credit” assignments as part of their regular work. Ms. M, however, was very proud of her father’s accomplishments. She spoke of her mother in conflicting terms as well: She was a homemaker, weak, and sometimes acquiescent to the powerful father but also a woman in her own right who was involved in community volunteer work and could be a powerful public speaker. Just prior to beginning her analysis, Ms. M had had her wallet stolen. In her first analytic session, she spoke of losing all of her identification cards, and to her it seemed as if she were starting analysis “with a completely new identity.” Initially, she was some- what hesitant to use the couch because she wanted to see her ana- lyst’s reactions, but she quickly appreciated that she could associate more easily without seeing the analyst. As her analysis proceeded, through dreams and free associa- tions, Ms. M became quite focused on the analyst. She became extremely curious about the analyst’s life. What emerged from her associations to seeing the analyst’s appointment book on the desk was that she felt “slotted in.” Whenever Ms. M saw other patients, she felt the office was “like an assembly line.” Further associations led to her feeling slotted in by her parents as they ran from one activity to another. Her resistance manifested itself in Ms. M’s often (Courtesy of T. Byram Karasu, M.D.)

1. High motivation. The patient needs a strong motivation to persevere, in light of the rigors of intense and lengthy treatment. The desire for health and self-understanding must surpass the neurotic need for unhappiness. The patient must be willing to face issues of time and money and to endure the pain and frustration associated with sacrificing rapid relief in favor of future cure and with foregoing the secondary gains of illness. 2. Ability to form a relationship. The capacity to form and maintain, as well as to detach from, a trusting object relationship is essential. The patient also has to withstand a frustrating and regressive transference without decompensating or becoming excessively attached. Patients with a history of impaired or transient interpersonal relations who cannot establish a viable connection to another human make poor candidates for psychoanalysis. 3. Psychological mindedness and capacity for insight. As an introspective process, psychoanalysis requires curiosity about oneself and the capacity for self-scrutiny. Those who are unable to articulate and comprehend their inner thoughts and feelings cannot negotiate with the fundamental analytical coin words and their meanings. The inability to examine one’s own motivations and behaviors precludes benefits from the analytical method. 4. Ego strength. Ego strength is the integrative capacity to oscillate appropriately between two antithetical types of ego functioning: On the one hand, the patient must be able to reflect temporarily, to relinquish reality for fantasy, and to be dependent and passive. On the other hand, the patient has to be able to accept analytical rules, to integrate interpretations, to defer important decisions, to shift perspectives to become an observer of his or her intrapsychic processes, and to function in a sustained interpersonal relationship as a responsible adult. coming as much or more than 15 minutes late to her sessions. Her associations led to her admitting that she did not want her analyst to think that she was “too eager.” Ms. M was able to see that she needed to devalue her analyst and her importance to Ms. M as a defense against an overwhelming positive and even erotic transfer- ence toward her. For example, Ms. M wanted to improve her appearance so that the therapist, who she called a “role model,” would find her more attractive. Her negative transference, however, was never far from the surface, and she denigrated the analyst by wondering if the ana- lyst were a “clotheshorse”who was financing her wardrobe with the patient’s payments. Her conflicts about her sexual orientation were a central preoc- cupation in the course of her analysis, particularly because her father was so homophobic. Early on, Ms. M felt awkward and uncomfort- able when she went to a lesbian bar, and when asked if she quali- fied for the “lesbian discount,” she said she did not. At one point, she began seeing several men, including a male psychologist. The analyst made the transference interpretation, which Ms. M accepted, that a date with this man seemed as if it were a date with the analyst and sleeping with him would be equivalent to sleeping with the ana- lyst. Ms. M was also able to see that her transient choice of dating a male therapist was a defensive compromise. Although her homosex- ual object choice was multidetermined, Ms. M came to appreciate, through her work in analysis, that at least a part of her conflicts about homosexuality stemmed from her relationship toward her father. It was a means of securing his attention as well as infuriating him. (Courtesy of T. Byram Karasu, M.D.)